Psychotherapy Integration Research Paper

The old dismissive debates that characterized the field of psychotherapy for more than a half a century have given way to a new relationship among proponents of different approaches—a relationship marked by mutual respect and serious efforts at conciliation (Gold, 1996; J. C. Norcross & Goldfried, 1992; Stricker, 1994; Stricker & Gold, 1993). The goal of this research paper is to present an overview of this movement of rapprochement and integration. First, we attempt to determine why the integration movement represents a significant force in the contemporary field of psychotherapy. We then describe what we perceive as the major trends within this movement. Finally, as a concluding note, we suggest where the integration movement should go in order to preserve its influence on the constantly evolving field of psychotherapy.

Integration: Whyand Why Now?

Why?

In our view, the integration movement represents an attempt to deal with the complexity of the process of change and the factors that are involved in facilitating such change. Although this view will most certainly reflect an epistemologically naive perspective, we would like to suggest that there might be some parallel between the growth of a professional and scientific tradition (such as the specific schools of psychotherapy) and the development of individuals (therapists in this case) in their attempts to better understand and deal with complex phenomena (such as psychopathology and psychotherapy; see Goldfried, 2001). More specifically, we would like to suggest that the development of major orientations in psychotherapy has followed—more or less neatly—three phases that many clinicians will recognize as significant markers of their professional growth.

Beginning clinicians often experience an initial period of excitement and discouragement. The pride, relief, and joy of having developed a cohesive treatment plan, established a supportive relationship, implemented skillfully a difficult procedure, or simply conducted a good session often give way to feelings of confusion and self-doubt; this occurs when our first successful cases (or sessions) are followed by struggles to articulate an elegant case formulation, to use in a timely fashion a technique that is perfectly attuned to the client’s need, to deal appropriately with a delicate problem in the therapeutic relationship, or simply to realize that session after session the client is not showing signs of improvement.

We would venture to guess that a similar process took place during the early days of the now well-established orientations and that the exhilaration of discovery experienced by pioneers of current forms of psychotherapy may have been quickly followed by frustrating discrepancies between their emergent theory and clinical observations. One can easily imagine how such a cyclical process of joys and tribulations might have prevailed in Freud’s professional life during the 1890s, when his initial successes with the cathartic method were followed by unexpected difficulties—leading him to develop the psychoanalytic method for the cure for hysteria. It would not surprise us to learn that Carl Rogers and Joseph Wolpe went through similar experiences during the 1950s when they were discovering the power of empathy or the clinical relevance (and effectiveness) of laboratory procedures used with cats. As exciting as these times may have been, we would expect that both men experienced significant setbacks when trying to apply their brilliant ideas to complicated cases.

This first phase of excitement and discouragement is frequently followed, we believe, by a period of confidence and rigidity. After a lot of observations, thinking, and trial and error, theoreticians and clinicians adopt models that help them organize (cohesively and heuristically) their views on human suffering and the process of change. Systematic rules of practice are defined for the clinicians, and acceptable methods of knowledge acquisition are delineated for the theoreticians and researchers. This time is also when training programs are institutionalized and when clinicians who have mastered the model and its related techniques become not only healers but also supervisors.

At this point, a deep sense of conviction and high level of enthusiasm may well have taken place in the individual practitioner as well as in the professional field. With such elation, however, then frequently comes the refusal to accept any dampening criticism that puts into question the brilliance of one’s theory and the unmistakable effectiveness of one’s interventions. Wariness of others’ explanations and ways of intervening is also characteristic of clinicians and theoreticians who are deeply (and blindly) committed to a particular orientation. The hazards of this stage have been denounced by reputed members of cognitive-behavioral (e.g., Thoresen & Coates, 1978), psychodyanamic (e.g., Strupp, 1976), and humanistic traditions (Koch, 1969, as cited in Ricks, Wandersman, & Poppen, 1976). Donald Levis (1998) vividly illustrated some of the manifestations and costs of these hazards for the behavioral approach:

Many behavioral therapists developed an extreme phobic reaction against anything that appeared to be Freudian in origin, to the point that even past history was considered unimportant, especially if it involved sexual or aggressive content. This phobic reaction soon developed in to an agoraphobic condition in which most, if not all, nonbehavioral contributions were avoided—even contributions that readily lend themselves to a learning interpretation. This myopic viewpoint created an anorexic condition for the field of behavior therapy which is leading to its ultimate starvation. It is ironic that the strengths of the behavior movement—its commitment to objective, scientific analysis, operational specificity, and principles of behaviorism—were overshadowed by the tendency to summarily dismiss without providing differential tests of a large body of existing literature, a literature which has evolved over the last 100 years as a result of extensive exposure to psychopathology and which, in most cases, is consistent with the tenets of behaviorism.

Although our theories and intervention methods allow us to assimilate clinical information and formulate various treatment plans, most of us (as therapists, theoreticians, or both) come to realize that there are some things we still cannot explain and some issues we cannot resolve successfully. Failures to understand and act effectively eventually lead most of us to adapt ourselves to a reality more complex than what we had originally recognized and adjust our theory and practice accordingly; this is when an individual clinician—or an orientation as a whole—emerges from the previous two stages with a sense of humility and openness for the potential contributions by those outside our domain. As described in the personal accounts of therapists who have gone through this developmental phase (Goldfried, 2001), the integration and eclectic movement in psychotherapy can be seen as a response (and by no means the only one) to the theoretical, clinical, and epistemological limitations of modern approaches to psychotherapy. It is a nondefeatist and noncomplacent response to the unsatisfactory status of our field—a response that is based on the assumption that the richness of plurality may be our best strategy to approach human complexity.

Why Now?

Many factors have fueled the prevailing attitude of humility and openness in the field of psychotherapy (see Norcross & Newman, 1992). In our view, the main three interrelated sources of input for the integration are (a) the eye-opening quality of numerous research findings, (b) the shortcomings of the prevalent theoretical models, and (c) the deficiencies of our clinical methods. We first consider some of the outcome and process research that has facilitated the emergence and development of the integration movement. We then explore some of the conceptual and clinical limitations that have been identified by respected members of each major orientation and that have stimulated efforts of rapprochement and conciliation.

Research

A cursory look to the psychotherapy outcome literature may lead one to feel quite positive about the field’s ability to address human psychological suffering. After all, research spanning five decades definitively shows that psychotherapy works (Lambert & Bergin, 1994). In addition, a substantial number of specific treatments have met fairly stringent methodological and clinical criteria, allowing them to be defined as empirically supported (see Kendall, 1998).

A closer look at the same literature, however, clearly reveals that psychotherapy is far from being a panacea. Although it has been shown to be superior to the lack of treatment, placebo interventions, and pseudotherapy, there is also unmistakable evidence that some clients fail to achieve full improvement, that others terminate treatment prematurely, and that yet others deteriorate during therapy (Garfield, 1994; Lambert & Bergin, 1994). Furthermore, the list of empirically supported treatments has stirred considerable controversy, most notably in terms of their relevance to the day-to-day practice and actual efficacy. There are indeed substantial differences in the type of clients who are treated and the conditions under which therapy is conducted in the clinical trials (where empirically supported treatments are tested) compared to clients and conditions in the clinician’s typical practice (see Jones in Castonguay, 1999).

Moreover, the success rate of many empirically supported treatments is not particularly impressive. For example, although cognitive-behavioral therapy (CBT) is the current gold-standard therapy for general anxiety disorder, only 50% of the clients who complete treatment show full recovery. Even outcome studies on behavioral treatment for phobia—a therapeutic choice that is likely to meet unanimity among most contemporary practitioners—shows how far we as therapists still have to go with regard to our ability to reduce psychological difficulties.Although the success of this treatment is high for those who complete therapy (75%), it drops substantially when one also considers clients who refuse to participate in treatment or drop out (49%; Barlow & Wolfe, 1981).

Apart from failing to demonstrate extraordinary curative powers of psychotherapy, outcome research has also shattered the often-held assumption that a preferred approach by any therapist is superior to other approaches. With the exception of fairly specific clinical problems (e.g., panic disorder, obsessive-compulsive disorder), major forms of psychotherapy appear to have an equivalent impact. Although on the positive side, one can see in this empirical finding a dodo verdict (everyone has won and therefore deserves a prize; Luborsky, Singer, & Luborsky, 1975), many in the field have concluded from it that each form of therapy can be improved and that a consideration of the contributions of other orientations may be the most efficient avenue for improving our therapeutic impact as clinicians.

In addition to outcome research in psychotherapy, investigations into therapy processes similarly indicate the need for humility and openness with regard to this area. Although we know that psychotherapy works, many theoreticians and practitioners seem to have misattributed the reasons for its success. Although most classic books and training programs associated with each major orientation tend to emphasize the skillful implementation of particular technical interventions, research suggests that 45% of the variance in outcome can be explained by placebo effects and factors common to several approaches (Lambert, 1992). In fact, recent studies have suggested that the adherence to techniques specifically prescribed by particular approaches can—at least in certain contexts—interfere with the client’s improvement (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996; Henry, Schacht, & Strupp, 1990; Henry, Strupp, Butler, Schacht, & Binder, 1993; Piper et al., 1999).

As described in the following discussion, a large number of therapeutic factors operating in several approaches (i.e., common factors) have been identified, and a number of them have been empirically investigated. Although the delineation of therapeutic commonalities represents an important contribution of the integration movement, it is also clear that variables that have been specifically associated with a particular orientation are related to treatment outcome. With recent scientific advances, however, it is becoming less certain that particular forms of therapy can actually claim sovereignty over some of these supposedly unique processes of change. For example, although emotional deepening has been highlighted as the fundamental route to therapeutic change in humanistic therapy, recent studies have demonstrated that such processes are also predictive of clients’ improvement in CBT (Castonguay et al., 1996; Castonguay, Pincus, Agras, & Hines, 1998). The principles of operant conditioning, assumed to explain the therapeutic power of procedures unique to behavior therapy, have been found to operate in both humanistic and psychodynamic treatment (Murray & Jacobson, 1971). Furthermore, although the concept of alliance was developed within the psychodynamic tradition, numerous empirical studies have shown that this construct explains a significant part of outcome variance across a variety of theoretical orientations (Constantino, Castonguay, & Schut, 2001). As discussed by Schut and Castonguay (2001), other processes of change initially defined by Freud and his followers have not only been shown to explain the efficacy of CBT but have also served as the basis for recent efforts to improve the therapeutic benefit of this approach.

We find it interesting that although research has supported a number of seminal insights of Freud about the process of change in psychodynamic therapy (see Schut & Castonguy, 2001), it has also suggested that part of the success of this type of treatment may be due to interventions typically identified with CBT. In summarizing the findings of a 30-year study on the process and outcome of different forms of psychodynamic therapy (expressive, supportive, and a mixture of expressive and supportive treatment) conducted at the Menninger Clinic, Wallerstein and DeWitt (1997) arrived at the following conclusion:

1. The treatment results, with patients selected either as suitable for trials at psychoanalysis, or as appropriate for varying mixes of expressive-supportive psychotherapeutic approaches, tended—with this population sample—to converge rather than diverge in outcome.

2. Across the whole spectrum of treatment courses in the 42 patients, ranging from the most analytic-expressive, through the inextricably blended, on to the most single-mindedly supportive, in almost every instance—the psychoanalyses included—the treatment carried more supportive elements than originally intended, and these supportive elements accounted for substantially more of the change achieved than had been originally anticipated.

3. The nature of supportive therapy, or better the supportive aspects of all psychotherapy, as conceptualized within a psychoanalytic theoretical framework, and as deployed by psychoanalytic knowledgeable therapists, bears far more respectful specification in all its form variants than has usually been accorded it in the psychodynamic literature . . .

4. From the study of the kinds of changes reached by this cohort of patients, partly on an uncovering insight-aiming basis, and partly on the basis of the opposed covering-up varieties of supportive techniques, the changes themselves—divorced from how they were brought about—often seemed quite indistinguishable from each other, in terms of being so-called real or structural changes in personality functioning. (pp. 141–142)

Considering the importance revealed by these results of supportive interventions in different forms of psychodynamic therapy, it is particularly interesting to observe how similar these components are to CBT’s technical repertoire. Included in Wallerstein and DeWitt’s list of supportive components are “persuading the phobic patient to enter the phobic situation”; “intellectual guidance, advice, objective review of situation, assisting the patient’s judgment”; “education in the form of advice, information, or suggestion in the direction of society’s normative standards and expectations”; “reduction of environmental demands on the patient”; “prescription of daily activities”; “planned disengagement from unfavorable and noxious (specifically conflict triggering) life situation”; “maintained engagement in particular (necessary and challenging) life situations”; and “altered interactions with, or alteration of attitudes, of significant others” (see Wallerstein & Dewitt, 1997, pp. 147–148).

Although several studies suggest that the effectiveness of one approach is in part accountable by the active ingredients identified by other orientations, it would be wrong to infer that the theories of change underlying the major therapeutic orientations are completely divorced from reality—that there are no links between clinical textbooks and practice. In fact, a number of studies have shown that cognitive, interpersonal, and psychodynamic therapies can be distinguished and that therapists can and do behave in ways that are consistent with particular models of interventions (e.g., Hill, O’Grady, & Elkin, 1992). However, two recent studies appear to suggest that the correspondence between theory and practice may be stronger in research contexts than it is in day-to-day practice.

These two studies were based on the Coding System of Therapist’s Focus (CSTF; Goldfried, Newman, & Hayes, 1989)—a process measure that allows for the identification of the therapist’s focus (or target) of intervention, regardless of the specific technique or treatment approach used. In both studies, the same forms of treatments were investigated— that is, CBT and psychodynamic interpersonal (PI) therapy. Furthermore, in each study the focus of the therapist was assessed in therapy sessions (or segments of sessions) that were classified as significant or helpful and less significant or less helpful. The primary difference between the two studies is that the first was based on archived data taken from a controlled clinical trial (the Sheffield II Psychotherapy Project; Goldfried, Castonguay, Hayes, Drozd, & Shapiro, 1997), whereas the other was based on therapy conducted in naturalistic settings (Goldfried, Raue, & Castonguay, 1998). Put another way, whereas the first study involved experienced therapists implementing manualized protocols, the second included expert clinicians (chosen by leaders of the field) conducting therapy as part of their regular clinical practice.

In the Sheffield study, many significant differences were found with regard to the therapists’ approaches. As would be predicted by the model of change of the investigated treatments, therapists in the PI (compared with therapists in CBT) focused more on emotion, discrepancies or incongruity between different aspects of client functioning, client avoidance, intrapersonal and interpersonal patterns in the client’s life, client’s expected reaction to others, impact of others on client’s life, client’s general interactions with others, parallels among people in client’s life, therapists themselves, client’s parents, client’s past (childhood and adult past), events taking place during therapy, and trends that cut across different life stages of the client. CBT therapists, however, focused more on the external environment, choices and decisions, information, support, homework, and the future. As summarized by the authors, the results suggest that the PI therapists focused on insight—more specifically, what has not worked in the past—whereas CBT focused on action—or how to deal more effectively with external events, especially with stressful events in the future.

It is interesting to note that although several differences in therapists’ focus were observed between the two therapies, only a small number of differences (slightly above chance level) were found between the types of session assessed— that is, therapists showed similar foci of interventions across helpful and less helpful sessions.

In the data set involving expert therapists, however, the opposite pattern of results was obtained. Specifically, although relatively few differences in therapists’ focus emerged between therapeutic orientations, numerous significant differences were obtained between significant and less significant parts of treatment sessions. Among other things, therapists focused more frequently on themselves, parallels between time periods and people in the client’s life, new information, and the future in significant segments as compared to less significant segments. As concluded by the authors, these targets of intervention reflect a blending of interventions strongly identified by each of the two approaches examined.

Taken together, the findings of these two studies appear to suggest that the day-to-day practices of expert therapists converge rather than diverge (regardless of their preferred orientation) and that the intervention focus of such therapists in good therapy is different from that in therapy that is less good. The findings also suggest that when investigating the target of intervention in manualized treatments, it is easy to discriminate between different approaches, but it is hard to find differences between helpful and less helpful sessions. As argued by Goldfried et al. (1998), these findings raise some interesting but complicated questions: “How do we as psychologists define the ‘state of the art’: Is it by the treatment manuals included in clinical trials or is it by what master therapists, who have been nominated by those who wrote the manuals, actually do in clinical practice?” (p. 809).

This brief—and no doubt biased—survey of the process and outcome literature directly points to the complexity of the process of change. Although different approaches are assumed to rest on divergent models of human functioning and are supposed to capitalize on unique techniques, none has been able to rely on empirical findings to claim superiority over the others across a variety of clinical problems. Furthermore, although the procedures prescribed by different approaches are typically assumed to be responsible for the client’s improvement, the percentage of outcome variance actually explained by these techniques is far from impressive. The success of one particular approach seems to be explained in part by variables that are common to all forms of psychotherapy and (ironically) by factors that have been closely associated with other orientations. To complicate things more, prescribed techniques have been shown to interfere with change, at least in certain contexts. Finally, despite the fact that the development of manualized treatments has been seen as indication of the field’s progress (Agras, 1999, referred to manuals as “nothing less than a scientific revolution”), experts in the field seem not to adhere to theoretical protocol and may well behave more similarly than dissimilarly—a point that was made a long time ago by Fiedler (1950).

As a whole, these empirical results indeed suggest that our current theories may not be adequate to explain the process of change. These results also point to the merits of considering the models and interventions of other orientations.

Theoretical and Clinical Disenchantments

Along with the research findings summarized previously, clinical and theoretical critiques voiced within each of the major orientations have also contributed to the current movement of reconciliation and integration in psychotherapy. In contrast to the enthusiasm (if not arrogance and complacence) for one’s own approach that prevailed until the 1960s, the last three decades have seen many therapists pointing out inadequacies of their preferred models and intervention methods.

In a courageous and eloquent critique of the school of thought with which he has been identified, Strupp (1976) asserted that

Once in the forefront of revolutionary change, psychoanalytic therapy is with increasing monotony described as antiquated, passé, and even defunct. Psychoanalytic theory is seen as based on formulations and working assumptions in dire need of massive overhaul . . . and psychoanalysis, as a branch of the behavioral sciences appears to be approaching its nadir. (p. 238)

Strupp further argued that instead of considering the writings of Freud and other analytic pioneers to be working hypotheses that can be improved, the closed-shop mentality that prevails in psychoanalytic training institutes has led psychoanalysts to treat them as gospel truth. He went on to say that the analytic establishment has discouraged collaboration between analytic therapists and researchers, and as a result the field of psychoanalysis has not benefited from advances in psychological and other behavioral sciences.

Like other influential psychoanalytic authors (e.g., Alexander, 1963; Grinker, 1976; Marmor, 1964), Strupp has convincingly argued that an adequate understanding of the process of change taking place within this orientation requires the consideration of many factors emphasized by learning theories. Marmor (1976, 1982), for instance, identified the following as key ingredients in psychoanalytic (or any other forms of) treatment: operant conditioning, suggestion and persuasion, cognitive learning, identification with the therapist, and explicit and implicit support from the therapist. Some psychodynamic authors have also emphasized the merit of considering the work of humanist-existential therapists in understanding the complexity of the process of change. For example, as part of an imaginary dialogue between a therapist of the traditional psychoanalytic approach and newer therapeutic approaches, Shectman (1977) has called attention to the existential therapy’s emphasis on the therapeutic role of emotions.

Influential psychodynamic authors have also questioned the validity and efficacy of the clinical procedures deemed sacred in many psychoanalytic institutes. Appelbaum (1979), for example, wrote

Some analytic thinkers believe, implicitly or explicitly, that overcoming repression will do it all, that once self-knowledge is achieved, nothing else needs to be done. This is, I assume, the way that most of those few but notorious ten to twenty years analyses come about, analyst and patient hooked on discovery, on the assumption that enough discovery will result in change, that around some corner is the ‘crucial insight.’ Such long-run analyses may make for good Woody Allen jokes, but to me they are horror stories. Pursuing insight, making the unconscious conscious, bringing what is out of awareness into awareness, making overt what is covert is not an unalloyed good for everyone at all time. (p. 434)

Appelbaum’s critical view of traditional psychoanalytic methods led him to explore many therapy centers closely identified with the humanistic movement. Although he relates having been shocked by some of the so-called interventions he witnessed, he also found practices that appeared complementary and therefore capable of improving psychodynamic technical repertoires. Similarly, Kahn (1991) also argued that a humanistic perspective has much to contribute to psychoanalytic practice, stating that “there is much to be learned by paying careful attention to Rogers’ advice about the relationship between therapist and client” (pp. 35–36). In a similar way, Wachtel (1977) has argued that behavioral techniques can be help clients develop and implement solutions to the dilemma with which they been confronted (e.g., inhibitions, distortions). As he notes, behavioral techniques “seem particularly valuable for accomplishing what dynamic therapists have regarded as the ‘working through’ stage of therapy” (1977, p. 203).

Freud himself, it appears, failed to meet the standards of proper practice that have been ascribed to psychoanalysis. A number of authors have noted that he deviated considerably from a blank-screen attitude with some of his patients.As described by Gill (1982), for example, Freud gave a meal and sent a postcard to the Rat Man.According toYalom (1980), he encouraged another patient (a young female named Elisabeth) to visit a young man whom she found attractive, interacted with members of her families on her behalf, begged her mother to communicate with the patient, and even helped untangle her family’s financial problems. Moreover, at the end of this young woman’s therapy, “Freud, hearing that Elisabeth was going to a private dance, procured an invitation to watch her ‘whirl past in a lively dance’ ”(Yalom, 1980, p. 4).

Well-known cognitive-behavioral therapists have also offered specific criticisms of their approach—both at theoretical and clinical levels. Voicing concerns similar to those of Strupp (1976) about the complacency of psychoanalysts, Thorensen and Coates (1978) commented that

The behavior therapies—born out of conflict with an authoritative and theoretically plump intrapsychic tradition, geared to survive in professionally tough clinical backgrounds, and recently afforded adult status as a legitimate professional approach—are showing signs of middle-aged bulge, theoretically, methodologically, and clinically. Success has bred a complacent orthodoxy which threatens to rob the behavior therapies of much of the scientific strength . . . For us an energy crisis clearly exists; resources are being wasted in defending, confirming, and replicating without substantially advancing our understanding . . . Critically examining and revising our conceptual rationale offers the most useful allocation of professional energies. We need to hack at the conceptual roots of behavior therapies to cut away the dead material, plant new ones, and graft together others . . . Submerged in all this is the neglect, less tangible, and yet significant role of personal meanings, goals, and aspirations—the purpose of life. (pp. 15–16)

It is interesting to note that some of the originators of the cognitive-behavioral movement have avoided the trap of complacence denounced by Thorensen and Coates (1978), even though their obvious investment in their approach may have made them more vulnerable to intellectual and professional rigidity. Lazarus (1971), for example, has urged his colleagues to move beyond the narrow theoretical model and restrictive technical repertoires of behavior therapy, even though he was one of the leading figures who paved the way for the recognition of this approach. Afew years after playing a predominant role in the birth and early development of the cognitive movement, Mahoney (1980) criticized this same approach by pointing out its narrow understanding and inadequate treatment of emotions, excessive emphasis on the role of rationality in adaptation, and neglect of unconscious processes. Echoing Thorensen and Coates’s (1978) criticism of behavior therapy, Mahoney also condemned the attitude of orthodoxy and defensiveness that had begun to emerge in cognitive and cognitive-behavioral approaches.

Disenchantment within the cognitive-behavioral movement has not only been voiced by pioneer figures like Lazarus and Mahoney. A survey conducted in the mid-1970s showed that both behavioral and cognitive therapists considered their approach to poorly capture the complexity of the process of change (Mahoney, 1978). More recently, Goldfried and Castonguay (1993) have argued that CBT places excessive emphasis on situational determinants of specific cognitive and behavioral responses and have asserted that more attention needs to be paid to the role of complex intrapersonal and interpersonal patterns in clients’functioning.

As was the case with dynamic authors, some leading cognitive-behavioral therapists have recognized their own tendencies toward heresy in the practice of their art. In their classic Clinical Behavior Therapy, for example, Goldfried and Davison (1976, 1994) wrote

We found instances where ‘insights’ occur to us in the midst of clinical sessions, prompting us to react in specific ways that paid off handsomely in the therapeutic progress of our clients . . . In accordance with most common definitions of behavior therapy, this might be viewed as heresy. Perhaps in some way it is. Nonetheless, our contact with reality is relatively veridical, and what we have observed under such instances is not terribly unique. If, in fact, some of these phenomena are reliable. . . . should we ignore them because we call ourselves behaviorists? (p. 16)

The importance of dealing with phenomena such as transference and resistance has been recognized by a number of cognitive-behavioral therapists (e.g., Beck et al., 1990; Goldfried, 1982; Rhoades & Feather, 1972). Authors such as Arnkoff (1981) and Goldfried (1985) have also demonstrated how the therapeutic relationship can be used to change cognitions and modify client’s behaviors. Citing the work of humanistic therapists (Greenberg & Safran, 1987), Samilov and Goldfried (2000) have recently argued for the recognition, withinCBTmodels,oftwodistincttypesofcognitions:(a)hot cognitions that are inextricably linked to the client’s immediate and prereflective sense of self-in-the-world and (b) cold cognitions that are governed by rules of logic and rationality and do not directly modify the client’s immediate experience. Samilov and Goldfried (2000) also encouraged their cognitive-behavioral colleagues to use techniques developed by experiential therapists when addressing hot cognitions because traditional CBT is seen as ill-suited for targeting this realm of experience.

In their attempt to delineate the clinical strengths and weaknesses of behavior therapy, Goldfried and Castonguay (1993) have argued that cognitive-behavioral therapists have too often failed to appropriately consider some dimensions of psychotherapy process that have been the focus of other orientations. They have argued that successful therapy sometimes requires exploring the client’s emotional experience and developmental history, recognizing and using the therapist’s own reactions in therapy, and dealing appropriately with issues that interfere with the therapeutic relationship. They also have argued that cognitive-behavioral therapists could increase their intervention repertoires by paying more attention to general principles of change as opposed to specific techniques prescribed in typical treatment manuals. A focus on these principles of change would indeed allow them to recognize that numerous non-CBT techniques serve many of the therapeutic functions that CBT interventions were intended to perform and that the former may be more effective than the latter in some specific circumstances or with some particular clients (see Castonguay, 2000a).

The humanistic approach, like others, has not been shielded from conceptual and clinical disenchantment. Koch (as cited in Ricks et al., 1976), one of the most important figures of the humanism tradition of psychology, has denounced its theoretical stagnation, methodological anarchy, and dogmatism. Others, such as Landsman (1974), have decried the type of practice often encountered in growth centers:

These, our finest jewels, offer a bewildering array of exotic mixtures, of sexuality unfettered, spirituality, meditation, and transcendence into infinity, solutions for the blahs, for Americans materialism, nude, erotic, and nonerotic massage, the most colorful exotic, light-headed excitements of all cultures and all times—and selling for about $75 to $150 per intimate, irresponsible weekend. (in Goldfried, 1982, p. 271)

Close examination of one of the most famous humanistic therapists, Carl Rogers, reveals that like preeminent psychodynamic and behavior therapists, he too employed methods other than those specified by his theory. Studies have indeed demonstrated that Rogers systematically and differentially applied reinforcements in reacting to client’s utterances (Jacobson & Murray, 1971). Rogers himself eloquently and courageously recognized the potential importance of social influence. In a review of a book entitled Models of Influence in Psychotherapy, Rogers (1981) wrote that the author (P. Pentony)

takes the multitude of present-day psychotherapies and, . . . with surgical objectivity, he analyzes each one—its premises, its strategies, its outcomes—and his knife often draws blood. I suspect most psychotherapists, as they see their work thus dissected, may react as I did—feeling first irritated, then disturbed, then challenged. The author’s central theme is that all therapists accomplish their goals by exerting social influence, and he analyzes carefully the varying forms of that influence.

Rogers completed his review by describing Pentony’s book as “a profound contribution.” Consistent with such comments, Rogers also wrote that the inherent limitations of using a single theoretical orientation—even his client-centered therapy— were beginning to outweigh the benefits and that psychotherapy research should focus upon empirical descriptions of what happens in therapy (see Goldfried & Newman, 1992).

Some authors have attempted to bridge Rogerian clientcentered therapy with psychodynamic self psychology (e.g., Tobin, 1990, 1991). These efforts at rapprochement are based on the premise that the developmental emphasis and interpersonal focus in self psychology can complement Rogerian therapy’s exclusive attention to the therapist’s relational skills (empathy, unconditional respect, authenticity). Others have encouraged humanistic therapists in general—not only those associated with a client-centered approach—to consider the merit of a rapprochement with other orientations (Greening, 1978; Landsman, 1974).

Current Developments in Psychotherapy Integration

The complexity of human functioning and difficulty of facilitating change have thus forced greater humility and openness within each of the major orientations of psychotherapy; this in turn has laid the foundation for the current swell of efforts at rapprochement and integration. Such efforts may be categorized into five domains: eclecticism, theoretical integration, common factors, integrative approaches to specific clinical problems, and the improvement of major systems of psychotherapy.

Eclecticism

Eclecticism is the application of diverse therapeutic techniques, without concern for whether the theoretical rationales behind the techniques are compatible (Lazarus, 1992). The greater emphasis on pragmatic utility over theoretical congruence has caused some to misattribute eclecticism as a hodgepodge of therapeutic techniques with no rhyme or reason (Eysenck, 1970). As cogently described by J. D. Norcross and Newman (1992), however, eclecticism needs to be differentiated from syncretism. Whereas eclecticism represents a systematic selection of “interventions based on patient need and comparative outcome research,” syncretism reflects a combination of techniques that is both uncritical and unsystematic—a “muddle of idiosyncratic and ineffable clinical creation” (p. 20).

A large number of eclectic approaches have been developed over the last 30 years. One of the first and most influential among them is Arnold Lazarus’s (1967, 1992) multimodal therapy. Based on an assessment of the client’s strengths and weaknesses related to seven modalities of functioning (e.g., behavior, affect, sensation, cognition), multimodal therapists are trained to use techniques (derived from divergent orientations) that are most likely to be useful. As stated by Lazarus (1992), the practice of multimodal therapy is guided by

(a) treatments of choice (i.e., knowing what the research literature has to say about specific remedies for particular problems); (b) tailored interventions (i.e., selecting psychotherapeutic strategies to fit patients’goals, coping behaviors, situational contexts, affective reactions, ‘resistances,’ and basic beliefs); and (c) therapists’ styles (i.e., going beyond formal diagnoses to match treatment styles to specific client characteristics). (p. 237)

Developed by Larry Beutler, systematic eclectic therapy (Beutler, 1983; Beutler & Consoli, 1992) is aimed at matching the client with the most appropriate therapist and treatment. Considered in constructing the optimal therapeutic match are (a) therapist and client demographic and background variables (e.g., ethnic similarity, attitudes, values, beliefs); (b) client characteristics (i.e., degree to which the client can receive directives without feeling threatened or reactance, extent of impairment due to client’s presenting problem or problem severity, whether the presenting problem is accompanied with an opaque or linear relation between symptoms and one’s pattern of behaviors or problem complexity, and the typical method of coping with stressors—e.g., externalizing vs. internalizing—or coping style); (c) the functions of various intervention procedures in terms of “breadth of objectives, the level of experience addressed, the amount of therapist directiveness required, and preference for intratherapy vs. extratherapy material” (Beutler & Consoli, 1992, p. 276). With Beutler, like Lazarus’s approach, priority is given to the individual client’s needs over theoretical considerations when selecting treatments.

In an interesting extension of Beutler’s client-treatment fit approach, Lampropoulos (2000a) has suggested a selective application of common factors depending on client and therapist styles and characteristics. For example, as the most robust common factor, the working alliance must still be tailored to each individual client’s particular expectations for therapy and his or her level of openness to experience.

Interested readers can find in Norcross’ (1986) Handbook of Eclectic Psychotherapy a description of other eclectic approaches, as well as a survey of eclectic efforts in Goldfried and Newman’s (1992) historical account of the integration movement. Several examples of combinations of techniques from divergent theoretical models are also illustrated in a book by Marmor and Woods (1980) entitled The Interface Between the Psychodynamic and Behavioral Therapies.

Theoretical Integration

Whereas eclectic therapists are interested in finding out the best way to selectively prescribe or pragmatically blend different techniques, those involved in theoretical integration attempt to extract constructs and therapeutic principles across many orientations and shape them into a new, more comprehensive, and integrated theory of functioning and/or change. Implicit in this undertaking is the belief that such inclusive theories will hold greater explanatory power than do any of the single theories from which it draws (Norcross & Newman, 1992).

Under the rubric of theoretical integration falls Prochaska and DiClemente’s (1992) transtheoretical model of therapeutic change. This model encompasses a series of stages through which clients progress in trying to alter problematic states of being. A number of processes have been identified within each of these stages to help clients achieve different levels of change. For example, if a client is identified to be in a stage called contemplation, a therapist would be encouraged to apply interventions that raise the client’s consciousness, engage the client’s affect through role playing, reevaluate his or her environment, or any combination of these in order to achieve symptom relief (Prochaska & DiClemente, 1992).

Along the same lines as Prochaska and DiClemente’s (1992) model of universal client change processes is William Stiles’s assimilation model (1992). Stiles contends that therapy consists of the assimilation of an originally threateningto-self experience into one’s cognitive-affective schemas (Stiles et al., 1992). To accomplish this goal, the client must first allow a problematic experience into awareness and endure the resultant painful thoughts and feelings—that is, assimilation is preceded by accomodation. Stiles has described a series of continuous and predictable stages through which clients traverse while undergoing therapeutic change. These stages, or levels of engagement with a problematic experience, are described as follows (Stiles et al., 1992):

• Stage 0: Warded Off. The individual is successfully avoiding engagement with the problem. Very little of the individual’s attentional resources are devoted to this issue (i.e., he or she is unaware of the problem).
• Stage 1: Unwanted Thoughts. The individual experiences unwanted thoughts about the problem. Strong negative affect occurs with the thoughts, and the individual still attempts to avoid the thoughts.
• Stage 2: Vague Awareness, Emergence. The problem is acknowledged as the ambiguous source of unwanted thoughts. Negative affect is very strong.
• Stage 3: Problem Statement, Clarification. Problem is clearly stated and acknowledged. Negative affect is present but less overwhelming.
• Stage 4: Understanding, Insight. The problematic experience is integrated into a schema with corresponding insight and understanding of the problem. Some affect may still be negative, but more positive emotions such as curiosity are also present.
• Stage 5: Application, Working Through. The individual uses newly gained understanding of the problem to devise problem-solving efforts (e.g., change in beliefs about the experience). Affect is primarily optimistic.
• Stage 6: Problem Solution. A solution is achieved for the problematic experience. Affect is positive with pride and satisfaction.
• Stage 7: The individual successfully applies new solution automatically. Affect is neutral because the problem has lost its salience to the individual.

Although they focus on different dimensions of psychotherapy, both Prochaska and DiClemente and Stiles offer new insights into the nature of client change processes, above and beyond the models of change underlying particular brands of therapy.

Perhaps the author most strongly associated with the trend of theoretical integration is Paul Wachtel (1977). His classic Psychoanalysis and Behavior Therapy: Toward an Integration offers an elegant synthesis of psychodynamic, interpersonal, and behavioral principles and practices. At the heart of his integrative approach is the concept of the psychodynamic vicious cycle,whichexplainsclientmaladaptiveinterpersonalpatterns. True to his psychodynamic background, Wachtel employs insight to gain perspective on the origin and manifestations (including client’s negative interpersonal expectations, the resulting problematic behaviors, and the expectation-confirming reactions of others) of such cycles. The major contribution of this approach, however, is Wachtel’s contention that these selffulfilling prophecies are currently reinforced through the client’s distorted perception of his or her behavior toward others and their behavior towards him or her. Behavioral methods are thus used to modify client’s ways of interacting with others (e.g., to bolster social skills), which helps break the current reinforcement of maladaptive interpersonal exchanges.

Several other integrative efforts have been described in collections edited by Goldfried (1982) and Marmor and Woods (1980). These efforts have also been reviewed in Arkowitz (1984) and Goldfried and Newman (1992). Integrative theories and practices have been described in an edited book by Stricker and Gold (1993), which in addition to including integrative approaches based on traditional forms of therapy (e.g., CBT and psychodynamic) also included examples of integration between traditional and nontraditional treatments (e.g., feminist therapy, Buddhism). Additionally, Arkowitz and Messer (1984) have edited a very interesting book on whether psychotherapy integration is possible or practical.

Common Factors

A third strand of psychotherapy integration is the search for factors that cut across various therapeutic orientations. Common factors have triggered the interest of some authors several years ago (e.g., Rosenweig, 1936), but it is clearly the work of Jerome Frank (1961) that has paved the way for the current recognition of these variables. Frank identified several features (i.e., therapeutic environment, therapeutic relationship, therapeutic rationale, and therapeutic tasks prescribed by the rationale) and therapeutic functions (e.g., increase hope, achieve cognitive and emotional learning, increase sense of mastery) that are shared not only by many forms of psychotherapy but also by most forms of healing (such as nonmedical rites in nonWestern cultures). A few authors (Garfield, 1957; Marmor, 1962) had also recognized the importance of common factors at the time of the publication of Frank’s (1961) classic Persuasion and Healing, but no other work has had more influence on authors who later discussed common factors. These authors— just to name a few—represent a large group: Bandler and Grinder (1975), Ehrenwald (1967), Goldfried and Padawer (1982), Harper (1974), London (1964), Marks and Gelder (1966), Masserman (1980), Sloane (1969), Strupp (1973), Torrey (1972), and Tseng and McDermott (1975).

Over time, a bewildering number of common factors have been described—close to 90, according to Grencavage and Norcross (1990). In order to bring some cohesion to this field, Castonguay (1987; Castonguay & Borgeat, 2001; Castonguay & Lecomte, 1989) has developed a transtheoretical model that integrates similarities within major dimensions of psychotherapy: Therapeutic framework (e.g., setting, assessment, contract), basic processes (i.e, therapist influence, client and therapist engagement, therapeutic relationship) and therapeutic acts (i.e, processes of communication, techniques and strategies of interventions). With the same purpose in mind—or, as they elegantly put it, to delineate commonalities among common factors—Grencavage and Norcross (1990) have organized common factors within five superordinate categories: client characteristics, therapist qualities, change processes, treatment structure, and relationship elements. Based on extensive review of process and outcome research, Orlinsky and Howard (1987) have also offered a generic model of psychotherapy:

to define the elements of the ‘genus’ psychotherapy—that is, the features that are common to the varied species of psychotherapy, however diverse the latter may be in the songs they sing and the colors they display to assure mutual recognition among colleagues … [and] to formulate psychotherapy simply in terms of its ‘active ingredients,’ disregarding the appeals of familiar brandname treatments whose patents on psychosocial therapies are expiring in this new age of eclecticism and integration. (pp. 6–7)

Despite the considerable attention they received, common factors were for a long time considered by many (especially behavior therapists) as secondary ingredients of change. Assumed to represent at best necessary but not sufficient conditions of change, common factors were frequently thought of as auxiliaries to the technique specifically prescribed by a particular approach (e.g., systematic desensitization). The accumulation of research findings, however, has forced most skeptics to reconsider the therapeutic role of these commonalities. Lambert (1992) argued that along with placebo effects, common factors explain about 45% of the outcome variance—compared to 15% of client improvement that appears to be due to specific techniques. Among these common factors, the working alliance now appears to be the most robust predictor of change across different forms and modalities of psychotherapy (Constantino et al., 2001).

In addition to being considered secondary variables in the process of change (or perhaps reflecting its second-class citizenship status), common factors have for a long time been equated to the so-called nonspecific variables. Inasmuch as nonspecific variables have been defined as interpersonal (or nontechnical) variables that have not yet been defined, equating the two types of variables has de facto imposed strict limitations on the types of variables that could be referred to as common factors.As pointed out by Castonguay (1993), this implies that no technical intervention has ever been used in more than one orientation. It also implies that none of the common factors so far have been clearly defined, operationalized, or both. It is clear, however, that a large number of techniques (e.g., reinforcement) and strategies of intervention (e.g., facilitating corrective experience) have been found to cut across different orientations. Moreover, a substantial number of them have been operationalized and measured reliably in many studies (e.g., working alliance, empathy). Fortunately, the field has become less inclined to use the term nonspecific (not only as a way to describe common factors, but in general) and has begun to refrain from relegating common factors to the status of nebulous (and inconsequential) processes of change. Lampropoulos (2000b) goes a step further in attempting to distinguish between the common factors that actually matter in a therapeutic sense and those common factors that either lack therapeutic potency or are too empirically vague to be studied. He suggests the following sequence of questions for determining whether a given variable is both common and therapeutically relevant: (a) Is the factor present in all or most therapies and (b) has the factor been empirically shown to relate to treatment outcome in most forms of therapy?An affirmative response to the aforementioned questions identifies a factor as both common and therapeutic.

Integrative Approaches for Specific Clinical Problems

A number of integrative treatments have been developed for specific clinical problems. Perhaps the two best known among them are Linehan’s dialectic-behavior therapy for borderline personality disorder and Wolfe’s therapy for anxiety disorders.

Linehan’s (1987) treatment rests on an eloquent etiological model, which posits that the combination of an early invalidating environment and a biological hypersensitivity to emotionality produces deficient emotional regulation processes that are central to the patient’s intrapersonal and interpersonal difficulties. Embedded in a context of emotional validation (i.e., acceptance techniques), behavioral interventions (i.e. change techniques) are used to actively teach and apply coping strategies related to emotional dysregulation. The balance between the use of acceptance and change techniques represents one of the many dialectical principles intrinsic to this complex and innovative treatment.Also used in this integrative intervention are paradoxical techniques, processexperiential attempts to deepen and experience powerful emotions, and dynamic insights to relate current patterns to past distressful experiences (Koerner & Linehan, 1992; Linehan, 1993).At the core of dialectic-behavior therapy is also the implementation of Zen principles, which allow clients, for example, to own seemingly contradictory wishes (e.g. to be loved and to guard against vulnerability), such that the resultant behaviors are seen as understandable reactions to these wishes— yet another dialectical principle.

Central to Wolfe’s approach is the premise that anxiety disorders are functionally related to many aspects of the client’s life—environmental as well as intrapsychic. Wolfe draws attention to the phenomenological sense of dread and insecurity that many people with anxiety disorders constantly face. He advocates strategies for decreasing the resulting persistent experiential avoidance of painful emotions. Phobias, for example, are treated with the standard behavioral techniques but are also examined for what Wolfe says are possible symbolic reflections of vulnerabilities resulting from early traumatic abandonment experiences.

Other integrative approaches have also begun to emerge. McCullough (2000), for example, has designed an integrative treatment for chronic depression—a clinical problem that has been particularly resistant to previous treatment efforts. Reflecting the author’s behavioral background, many components of this treatment involve the clinical implementation of conditioning principles, such as the identification of contingencies (especially negative reinforcements) and the modification of behaviors through techniques like assertion training. The treatment also includes interventions and intervention foci that have been associated with other theoretical traditions in psychology and psychotherapy. Among them are training in social problem solving reflective of Piaget’s stage of formal operations, the use of therapist experience to provide feedback to clients on their impact on others, and identification and challenge of transference issues.

With the goal of improving the efficacy of CBT—the current gold-standard treatment—for generalized anxiety disorder, Newman, Castonguay, and Borkovec (1999; Newman, Castonguay, Borkovec, & Molnar, in press) have developed a treatment that combines CBT interventions with techniques used in humanistic, interpersonal, and psychodynamic therapies. The choice of the specific techniques added to CBT was based on both basic and applied research findings. For instance, procedures to deepen emotions (e.g., two-chair approach) have been added based on studies suggesting that worry, the central feature of generalized anxiety disorder, serves as a cognitive avoidance of painful emotion (Borkovec, Newman, & Castonguay, 1998). Also included are interventions designed to address interpersonal issues (in and outside the therapy) based on findings indicating that failure to solve interpersonal problems at the end of CBT predicts worse response at follow-up (Borkovec, Newman, Pincus, & Little, in press). Although process studies have demonstrated that emotional deepening and the exploration of specific interpersonal issues (e.g., relationship with parents or with therapist) are predictive of improvement in CBT (Castonguay et al., 1996; Castonguay et al., 1998; Hayes, Castonguay, & Goldfried, 1996; Jones & Pulos, 1993), research evidence has also shown that these issues are not typically emphasized in this approach, at least in comparison with psychodynamic therapy (Blagys & Hilsenroth, 2000). In contrast, this integrative treatment allows for a direct and systematic processing of these issues while continuing to emphasize the coping skills component that is part of CBT.

Other integrative approaches for specific problems (e.g., substance abuse, organic disorder, depression, chronic pain, severe mental disorders), populations (e.g., children, adolescents, older persons), and treatment modalities (e.g., couple, family, group, medication, and psychotherapy) have been described in Norcross and Goldfried (1992) and Stricker and Gold (1993).

Improvement of Major Systems of Psychotherapy

The goal of the integration movement is not to create a new school of therapy, wherein all would define themselves as eclectic or integrative therapists. One can pursue the ultimate aims of integration (i.e., to deepen our understanding of change and increase the effectiveness of psychotherapy by considering the potential contributions of several orientations) while remaining primarily attached to one particular approach. Rapprochement with others, in other words, does not imply a rejection of one’s own professional identity. As we have argued elsewhere (Goldfried & Castonguay, 1992), the three major orientations (psychodynamic, humanistic, and CBT) are solidly entrenched in our professional landscape. On the other hand, respected members of each of these particular schools have attempted to improve their approach by integrating constructs and clinical venues developed in other traditions. This type of integration has been defined by Messer (1992, 2001) as assimilative integration. In Messer’s (2001) words, this term refers to “the incorporation of attitudes, perspectives, or techniques from an auxiliary therapy into a therapist’s primary, grounding approach” (p. 1).

Many of the contributions described in this research paper’s section on theoretical and clinical disenchantment represent efforts of this sort. However, some authors have offered more extensive and elaborated assimilations of divergent concepts and methods, thereby offering new models within a particular tradition. For instance, arguing that humanistic-existential approaches have failed to provide an adequate understanding of character pathologies, Bouchard (1990) has demonstrated how such problems can be corrected by elegantly integrating psychoanalytic concepts (i.e., Fairbairn, 1954) within Gestalt theory. Gold and Stricker (2001) have argued that recent developments within the psychodynamic orientation have led to a cohesive framework (cogently described by Mitchell, 1988, as relational psychoanalysis) allowing psychodynamically oriented therapists to integrate within their clinical repertoire several strategies of interventions traditionally emphasized in nonpsychoanalytic orientations (e.g., interventions to change relationships outside therapy and to support clients’ active efforts at change).

Perhaps the best-known attempt to improve one orientation by relying on the contributions of other tradition is the work of Jeremy Safran (Safran, 1990a, 1990b; Safran & Segal, 1990). As captured by the title of one of his books, a significant portion of his theoretical, clinical, and empirical contributions has been aimed at “widening the scope of cognitive therapy” (Safran, 1998). His consideration of humanistic, interpersonal, and psychodynamic traditions allows for a recognition of four dimensions of human functioning (i.e., emotional, developmental, interpersonal, and conflictual) that have been frequently disregarded in CBT models; it also allows for an integration of non-CBT methods to address the determinants of behaviors associated with these dimensions of functioning (see Castonguay, 2001, for a summary).

Expanding upon Messer’s notion of assimilative integration, Lampropoulos (2000) offered concrete suggestions for how therapists can integrate other technical and theoretical components of other modalities in a cohesive and ultimately therapeutic manner. Specifically, he advocates that only empirically validated techniques be incorporated into one’s main theoretical orientation, that to-be-integrated techniques fit the context already established by the main orientation, and that the final product of a theory with assimilated aspects of other theories remains internally consistent and the main theoretical and technical tenets stay intact.

Concluding Notes: Future Directions

Despite being relatively young, the integration movement has served as the vehicle for several interesting developments in the field of psychotherapy. It seems clear, however, that more needs to be done for this movement to be able to fulfill its promise of significantly improving our understanding of the process of change and to substantially increase the efficacy of our interventions. It is clear to us that both theoretical and clinical advances can and should take place within each of the five domains of integration covered in the previous section. We also believe that to ensure its optimal development (if not survival), more attention should be given in the near future to two areas that are crucial to any school or trend in psychotherapy—training and research.

Training

The quality of training can be seen as a barometer for the maturity of a professional domain. Reflecting their solid establishment in contemporary psychotherapy, humanistic, psychodynamic, and cognitive-behavioral approaches have generated systematic, rigorous, and cohesive training programs (both graduate and postgraduate). Until recently, however, training efforts in psychotherapy integration could be described for the most part as unsystematic and poorly articulated (Castonguay, 2000b). As Robertson (1986) cogently noted, one of the problems facing eclectic and integrative training is

a scarcity of training faculty who are committed to and competent in the theory and practice of integrative-eclectic psychotherapy. Too often, therapy trainers (and I have to include myself) teach eclecticism in the form of value statements instead of value actions. It is hoped that we will not transmit this limitation to the generation of eclectic therapy trainers. (p. 432)

It would be inaccurate to say that training has not received attention in the integration movement. In fact, a training committee has for several years been an important part of the Society for the Exploration of Psychotherapy Integration (SEPI; for more information about the organization, please visit http://www.cyberpsych.org/sepi/). In addition, several important training issues have been debated for some time and continue to be the focus of current discussion within the integration movement (see Castonguay, in press; Consoli & Jester, in press; Gold, in press; Lecomte, Castonguay, Cyr & Sabourin, 1993). Among these issues are the use of an integrative-eclectic model as a starting or ending point of one’s training, the focus of supervision (exploring the supervisee-supervisor relationship or learning-specific techniques of interventions), characteristics required from students and trainers, the specific challenges and anxieties associated with integrative learning, and the place of formal training in research.

With a few exceptions (e.g., Lecomte et al., 1993), however, what has been missing is the articulation and implementation of structured and cohesive integrative training programs. In line with Robertson’s (1986) hope that systematic training programs will be available to the next generation of eclectic-integrative trainers, a recent series of papers published in the Journal of Psychotherapy Integration has provided a description of current and future training efforts related to three major trends of psychotherapy integration: theoretical integration (Wolfe, 2000), pragmatic eclecticism (Norcross & Beutler, 2000), and common factors (Castonguay, 2000a). Each paper describes ways in which the authors are actually training students in their own preferred mode of integrative thinking and practice.Also presented are scaffolds of comprehensive training programs that the authors envisioned as ideal from their own perspective.Although such efforts and ideas represent good starting points, much more energy needs to be devoted in the future to articulate, build, and evaluate integrative training programs.

Research

Research has clearly lagged behind the commitment shown toward theoretical and clinical development by individuals interested in psychotherapy integration. Nevertheless, empirical efforts have begun to provide support to this growing movement. In fact, a number of studies have been conducted within each of the trends described in the previous section.

A considerable number of studies have been conducted with respect to two of the approaches representing the theoretical integration perspective.As described by Prochaska and DiClemente (1992), the constructs of stages, processes, and levels of change (which are at the core of their transtheoretical approach) have been validated. In addition, the predictive validity of the stages and processes of change has been established with respect to premature termination, short-term outcome, and long-term outcome. Furthermore, stage-matching interventions for smoking cessation have shown promising results compared to those of the current gold-standard treatment. Both quantitative and qualitative research has also endorsed the construct and predictive validity of Stiles’s assimilaton model (Field, Barkham, Shapiro, & Stiles, 1994; Stiles, Meshot, Anderson, & Sloan, 1992; Stiles, Shankland, Wright, & Field, 1997). For instance, clients who come to therapy with problems located at higher levels of assimilation achieved better outcomes in CBT compared to interpersonal therapy—a finding that is consistent with the assumption that well-assimilated problematic experiences require therapeutic techniques geared toward the client’s activating new behaviors (Stiles et al., 1997). The findings of a qualitative study on the process of assimilation in process-experiential psychotherapy for depression suggest that progress in assimilation accounted for one client’s superior outcome, whereas the lack of gains in assimilation across the course of treatment could plausibly explain another client’s poor outcome (Honos-Webb et al., 1998).

With regard to eclecticism, the empirical work of Larry Beutler and his colleagues has provided helpful guidelines for prescribing the types of treatment that may be most indicated for particular clients (see Beutler & Consoli, 1992). For instance, their findings suggest that clients who tend to be highly reactive (i.e., reluctant to be controlled by others) should be prescribed interventions that are nondirective in nature (e.g., supportive therapy), whereas directive forms of interventions (e.g., CBT or focused-expressive therapy) appear to be indicated for individuals who are less reactive. In addition, insight-oriented therapies (e.g., supportive therapy or focused-expressive therapy) seem to be appropriate for individuals who cope with stress by internalizing their problems (e.g., self-blame), whereas symptomfocused treatment (e.g., CBT) may be a better fit for individuals who externalize (i.e., who blame others or external circumstances for their problems) when confronted with stress.

A number of common factors have been investigated. These factors include variables such as expectancies, working alliance, empathy, and corrective emotional experience (Arnkoff, Victor, & Glass, 1993; Castonguay & Borgeat, 2000; Lambert, 1992; Weinberger, 1993). As described earlier in this research paper, a variety of factors assumed to be unique to one orientation (e.g., emotional deepening, exploration of the past, behavioral activation techniques) also appear to cut across different approaches.

Several of the integrative treatments that have been developed to address particular forms of clinical problems have also been submitted to empirical investigations. Chief among them is Linehan’s dialectic-behavior therapy for borderline personality disorder. A substantial number of efficacy studies have been conducted on this treatment and reviewed in several recent publications (e.g., Koerner & Dimeff, 2000; Koerner & Linehan, 2000; Linehan, Cochran, & Cochran, 2001). As summarized by Koerner and Linehan (2000),

Research evidence to date indicates that, although DBT[dialecticbehaviortherapy]wasdevelopedforthetreatmentofpatientswith suicidal behavior, it can be adapted to treat BPD [borderline personality disorder] patients with comorbid substance-abuse disorder and be extended to other patient populations and the treatment of other disorders. Across studies, DBT seems to reduce severe dysfunctional behaviors that are targeted for intervention (e.g., parasuicide, substance abuse, and binge eating), enhance treatment retention, and reduce psychiatric hospitalization. (p. 164)

Furthermore, process findings have provided support to one of the core aspects of Linehan’s model of change by demonstrating that a balance of therapist acceptance and change was associated with clients’improvement (Shearin & Linehan, 1992).

Although its findings are preliminary, a recent study on the integrative therapy for generalized anxiety disorder described earlier indicates that a sequential combination of CBT and I/EPcomponents is not only feasible (as suggested by numerous process measures, including the level of adherence and competence achieved by therapists), but it also appears to lead to higher pre-post treatment effect sizes than does traditional CBT for GAD (see Newman et al., in press). In addition, impressive findings for the efficacy of McCullough’s cognitive behavioral-analysis system in combination with medication (Nefazodone) were recently published in the prestigious New England Journal of Medicine (Keller et al., 2000).Aresponse rate of 85% (for completers) was obtained on a large sample of individuals suffering from chronic depression.

As an example of the fifth trend of the integration movement (i.e., efforts to improve effective forms of therapy), Castonguay (2000) provided a first efficacy test of an integrative-cognitive therapy (ICT) for depression. The study was based on earlier process findings, which suggested that therapists’ adherence to the prescribed rationale and techniques in cognitive therapy may interfere with positive outcome when used to address alliance ruptures (Castonguay et al., 1996). Specifically, ICT requires therapists to follow the traditional cognitive therapy protocol (Beck, Rush, Shaw, & Emery, 1979), except when confronted with alliance ruptures. Following the guidelines described by Burns (1990), Safran and Segal (1990), and Linehan (1993), therapists are then instructed to use techniques derived from (or similar to interventions used in) humanistic and interpersonal therapies (e.g., empathy, exploration of therapist’s contribution to ruptures) to resolve the relationship difficulties. Although findings are still preliminary, they suggest that ICT is not only superior to a waiting-list condition, but it also compares favorably to traditional cognitive therapy for depression.

Despite the promising nature of the aforementioned studies, it remains imperative for individuals invested in the integration movement to devote more energy into research. As Glass, Victor, and Arnkoff (1993) cogently argued, although current research represents a solid beginning, “it is clear that there are nearly unlimited avenues for future study” (p. 20). Considering the pressure for accountability that is imposed on mental health professionals, the onus is on integrative researchers to demonstrate that this movement can indeed lead to a better understanding of the complexity of the process of change and more effective ways of dealing with human suffering.

Bibliography:

1. Alexander, F. (1963). The dynamics of psychotherapy in light of learning theory. American Journal of Psychiatry, 120, 440–448.
2. Appelbaum, S. A. (1979). Out in inner space: A psychoanalyst explores the therapies. Garden City, NY: Anchor.
3. Arkowitz, H. A. (1984). Historical perspective on the integration of psychoanalytic therapy and behavioral therapy. In H.Arkowitz & S. Messer (Eds.), Psychoanalytic therapy and behavior therapy (pp. 1–30). New York: Plenum Press.
4. Arkowitz, H., & Messer, S. B. (Eds.). (1984). Psychoanalytic and behavior therapy: Is integration possible? New York: Plenum Press.
5. Arnkoff, D. B. (1981). Flexibility in practicing cognitive therapy. In G. Emery, S. D. Hollon, & R. C. Bedrosian (Eds.), New directions in cognitive therapy (pp. 203–223). New York: Guilford Press.
6. Arnkoff, D. B., Victor, B. J., & Glass, C. R. (1993). Empirical research on integrative and eclectic psychotherapies. In G. Stricker & J. Gold (Eds.), Comprehensive handbook of psychotherapy integration (pp. 9–26). New York: Plenum Press.
7. Bandler, R., & Grinder, J. (1975). The structure of magic. United States: Science and Behavior Books.
8. Barlow, D. H., &Wolfe, B. E. (1981). Behavioral approaches to anxiety disorders: A report on the NIMH-SUNY, Albany, Research Conference. Journal of Consulting and Clinical Psychology, 49, 448–454.
9. Beck, A. T., Freeman, A., & Associates. (1990). Cognitive therapy of personality disorders. New York: Guilford Press.
10. Beck, A. T., Rush, J. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy for depression. New York: Guilford Press.
11. Beutler, L. E. (1983). Eclectic psychotherapy: A systematic approach. Elmsford, NY: Pergamon Press.
12. Beutler, L. E., & Consoli, A. J. (1992). Systematic eclectic psychotherapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 264–299). New York: Basic Books.
13. Blagys, M. D., & Hilsenroth, M. J. (2000). Distinctive features of short-term psychodynamic-interpersonal psychotherapy: A review of the comparative psychotherapy process literature. Clinical psychology: Science and practice, 7, 167–188.
14. Borkovec, T. D., Newman, M. G., & Castonguay, L. G. (1998, November). The potential role of interpersonal emotional processing in the treatment of Generalized Anxiety Disorder. Paper presented at the Annual meeting of the Association for the Advancement of Behavior Therapy, Washington, DC.
15. Borkovec, T. D., Newman, M. G., Pincus, A., & Lytle, R. (in press). Acomponent analysis of cognitive-behavioral therapy for generalized anxiety disorder and the role of interpersonal problems. Journal of Consulting and Clinical Psychology.
16. Bouchard, M. A. (1990). De la phenomenologie a la psychanalyse. Bruxelles: Pierre Mardaga.
17. Burns, D. D. (1990). The feeling good handbook. New York: Plume.
18. Castonguay, L. G. (1987). Rapprochement en psychotherapie: Perspectives theoriques, cliniques, et empiriques. In C. Lecomte & L. G. Castonguay (Eds.), Rapprochement et integration en psychotherapie: Psychanalyse, behaviorisme et humanisme. Chicoutimi: Gaetan Morin.
19. Castonguay, L. G. (1993). “Common factors” and “nonspecific variables”: Clarification of the two concepts and recommendations for research. Journal of Psychotherapy Integration, 3, 267–286.
20. Castonguay, L. G. (2000a). A common factors approach to psychotherapy training. Journal of Psychotherapy Integration, 10, 263–282.
21. Castonguay, L. G. (2000b). Training in psychotherapy integration: Introduction to current efforts and future visions. Journal of Psychotherapy Integration, 10, 229–232.
22. Castonguay, L. G. (in press). Issues in psychotherapy training. Journal of Psychotherapy Integration.
23. Castonguay, L. G., & Borgeat, F. (2001). Les mécanismes de base en psychothérapie. In P. Lalonde, J. Aubut, & F. Grunberg (Eds.), Psychiatrie clinique: Approche bio-psycho-sociale. Chicoutimi: Gaetan Morin.
24. Castonguay, L. G., Goldfried, M. R., Wiser, S., Raue, P. J., & Hayes, A. H. (1996). Predicting outcome in cognitive therapy for depression: A comparison of unique and common factors. Journal of Consulting and Clinical Psychology, 64, 497–504.
25. Castonguay, L. G., & Lecomte, C. (1989, April). The common factors in psychotherapy: What is known and what should be known. Paper presented at the 5th Annual Meeting of the Society for the Exploration of Psychotherapy Integration, San Francisco.
26. Castonguay, L. G., Pincus, A. L., Agras, W. S., & Hines, C. E. (1998). The role of emotion in group cognitive-behavioral therapy for binge eating disorder: When things have to feel worst before they get better. Psychotherapy Research, 8, 225–238.
27. Consoli, A. J., & Jester, C. M. (in press). A model for teaching psychotherapy theory through integrative structure. Journal of Psychotherapy Integration.
28. Constantino, M. J., Castonguay, L. G., & Schut, A. J. (2001). The working alliance: A flagship for the scientific-practitioner model in psychotherapy. In G. Shick Tryon (Ed.), Counseling based on process research (pp. 81–131). New York: Allyn and Bacon.
29. Eysenck, H. J. (1953). Uses and abuses of psychology. Baltimore: Penguin Books.
30. Eysenck, H. J. (1970). A mish-mash of theories. International Journal of Psychiatry, 9, 140–146.
31. Fairbairn, W. R. D. (1954). An object relations theory of the personality. New York: Basic Books.
32. Field, S. D., Barkham, M., Shapiro, D. A., & Stiles, W. B. (1994). Assessment of assimilation in psychotherapy: A quantitative case study of problematic experiences with a significant other. Journal of Counseling-Psychology, 41, 397–406.
33. Fiedler, F. E. (1950). A comparison of therapeutic relationships in psychoanalytic, nondirective, and Adlerian therapy. Journal of Consulting Psychology, 14, 436–445.
34. Frank, J. D. (1961). Persuasion and healing. Baltimore: Johns Hopkins University Press.
35. Garfield, S. L. (1957). Introductory clinical psychology. New York: MacMillan.
36. Garfield, S. L. (1994). Research on client variables in psychotherapy. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed., pp. 190–228). New York: Wiley.
37. Gill, M. M. (1982). Analysis of transference, Vol. 1: Theory and technique. New York: International Universities Press.
38. Gold, J. R. (in press). Anxiety, conflict and resistance in learning an integrative perspective on psychotherapy. Journal of Psychotherapy Integration.
39. Gold, J. R. (1996). Key concepts in psychotherapy integration. New York: Plenum Press.
40. Gold, J. R., & Stricker, G. (2001). A relational psychodynamic perspective on assimilative integration. Journal of Psychotherapy Integration, 11, 43–58.
41. Goldfried, M. R. (Ed.). (1982). Converging themes in psychotherapy: Trends in psychodynamic, humanistic, and behavioral practice. New York: Springer.
42. Goldfried, M. R. (1985). In vivo intervention or transference? In W. Dryden (Ed.), Therapist’s dilemmas. London: Harper and Row.
43. Goldfried, M. R. (Ed.). (2001). How therapists change: Personal and professional reflections. Washington, DC: American Psychological Association.
44. Goldfried, M. R., & Castonguay, L. G. (1993). Behavior therapy: Redefining strengths and limitations. Behavior Therapy, 24, 505–526.
45. Goldfried, M. R., Castonguay, L. G., Hayes, A. H., Drozd, J. F., & Shapiro, D. A. (1997). A comparative analysis of the therapeutic focus in cognitive-behavioral and pychodynamic-interpersonal sessions. Journal of Consulting and Clinical Psychology, 65, 740– 748.
46. Goldfried, M. R., & Davison, G. C. (1976). Clinical behavior therapy. New York: Holt, Rinehart, & Winston.
47. Goldfried, M. R., & Davison, G. C. (1994). Clinical behavior therapy. New York: Wiley.
48. Goldfried, M. R., & Newman, C. F. (1992). Ahistory of psychotherapy integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 46–93). New York: Basic Books.
49. Goldfried, M. R., Newman, C. F., & Hayes, A. M. (1989). The coding system of therapeutic focus. Unpublished manuscript, State University of New York, Stony Brook.
50. Goldfried, M. R., & Padawer, W. (1982). Current status and future directions in psychotherapy. In M. R. Goldfried (Ed.), Converging themes in psychotherapy (pp. 3–49). New York: Springer.
51. Goldfried, M. R., Raue, P. J., & Castonguay, L. G. (1998). The therapeutic focus in significant sessions of master therapists: A comparison of cognitive-behavioral and psychodynamicinterpersonal interventions. Journal of Consulting and Clinical Psychology, 66, 803–811.
52. Greenberg, L. S., & Safran, J. D. (1987). Emotion in psychotherapy. New York: Guilford Press.
53. Greenberg, L. S., Watson, J. C., & Lietaer, G. (1998). Handbook of experiential psychotherapy. New York: Guilford Press.
54. Greening, T. C. (1978). Commentary. Journal of humanistic psychology, 18, 1–4.
55. Grencavage, L. M., & Norcross, J. C. (1990). Where are the commonalties among the therapeutic common factors? Professional Psychology: Research and Practice, 5, 372–378.
56. Grinker, R. R. (1976). Discussion of Strupp’s, “Some critical comments on the future of psychoanalytic therapy.” Bulletin of the Menninger Clinic, 40, 247–254.
57. Harper, R. (1974). Psychoanalysis and psychotherapy. New York: Jason Aronson.
58. Hayes, A. H., Castonguay, L. G., & Goldfried, M. R. (1996). The effectiveness of targeting the vulnerability factors of depression in cognitive therapy. Journal of Consulting and Clinical Psychology, 64, 623–627.
59. Henry, W. P., Schacht, T. E., & Strupp, H. H. (1990). Patient and therapist introject, interpersonal process, and differential psychotherapy outcome. Journal of Consulting and Clinical Psychology, 58, 768–774.
60. Henry, W. P., Strupp, H. H., Butler, S. F., Schacht, T. E., & Binder, J. L. (1993). Effects of training in time-limited dynamic psychotherapy: Changes in therapist behavior. Journal of Consulting and Clinical Psychology, 61, 434–440.
61. Hill, C. E., O’Grady, K. E., & Elkin, I. (1992). Applying the collaborative study psychotherapy rating scale to rate therapist adherence in cognitive-behavior therapy, interpersonal therapy, and clinical management. Journal of Consulting and Clinical Psychology, 60, 73–79.
62. Jones, E. E., & Pulos, S. M. (1993). Comparing the process in psychodynamic and cognitive-behavioral therapies. Journal of Consulting and Clinical Psychology, 61, 306–316.
63. Kahn, M. (1991). Between therapist and client: The new relationship. New York: W. H. Freeman.
64. Keller, M. B., McCullough, J. P., Klein, D. N., Arnow, B., Dunner, D. L., Gelenberg, A. J., Markowitz, J. C., Nemeroff, C. B., Russell, J. M., Thase, M. E., Trivedi, M. H., & Zajecka, J. (2000). A comparison of nefazodone, the cognitive behavioralanalysis system of psychotherapy, and their combination for the treatment of chronic depression. New England Journal of Medicine, 342, 1462–1470.
65. Kendall, P. C. (1998). Empirically supported psychological therapies. Journal of Consulting and Clinical Psychology, 66, 3–6.
66. Koerner, K., & Dimeff, L. A. (2000). Further data on dialectical behavior therapy. Clinical psychology: Science and Practice, 7, 104–112.
67. Koerner, K., & Linehan, M. M. (1992). Integrative therapy for borderline personality disorder: Dialectical behavior therapy. In M. Goldfried & J. Norcross (Eds.), Handbook of psychotherapy integration (pp. 433–459). New York: Basic Books.
68. Lambert, M. J. (1992). Psychotherapy outcome research: Implications for integrative and eclectic therapists. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 94–129). New York: Basic Books.
69. Lambert, M. J., & Bergin, A. E. (1994). The effectiveness of psychotherapy. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed., pp. 143–189). New York: Wiley.
70. Lampropoulos, G. K. (2000a). Evolving psychotherapy integration: Eclectic selection and prescriptive applications of common factors in therapy. Psychotherapy, 37, 285–297.
71. Lampropoulos, G. K. (2000b). Definitional and research issues in the common factors approach to psychotherapy integration: Misconceptions, clarifications, and proposals. Journal of Psychotherapy Integration, 10, 415–438.
72. Lampropoulos, G. K. (2001). Bridging technical eclecticism and theoretical integration: Assimilative integration. Journal of Psychotherapy Integration, 11, 5–19.
73. Landsman, T. (1974, August). Not an adversity but a welcome diversity. Paper presented at the meeting of the American Psychological Association, New Orleans, LA.
74. Lazarus, A. A. (1967). In support of technical eclecticism. Psychological Reports, 21, 415–416.
75. Lazarus, A. A. (1971). Behavior therapy and beyond. New York: McGraw-Hill.
76. Lazarus, A. A. (1992). Multimodal therapy: Technical eclecticism with minimal integration. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 231–265). New York: Basic Books.
77. Lecomte, C., Castonguay, L. G., Cyr, M., & Sabourin, S. (1993). Supervision and instruction in doctoral psychotherapy integration. In G. Stricker & J. R. Gold (Eds.), Comprehensive handbook of psychotherapy integration (pp. 483–498). New York: Plenum
78. Levis, D. J. (1988). Observations and experience from clinical practice: A critical ingredient for advancing behavior theory and practice. The Behavior Therapist, 11, 95–99.
79. Linehan, M. M. (1987). Dialectical behavior therapy for borderline personality disorder: Theory and method. Bulletin of the Menninger Clinic, 51, 261–276.
80. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.
81. Linehan, M. M., Cochran, B. N., & Cochran, C. A. (2001). Dialectical behavior therapy for borderline personality disorder. In D. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (3rd ed., pp. 470–522). New York: Guilford Press.
82. London, P. (1964). The modes and morals of psychotherapy. New York: Holt, Rinehart, & Winston.
83. Luborsky, L., Singer, B., & Luborsky, L. (1975). Comparative studies of psychotherapies: Is it true that “Everyone has won and all must have prizes?” Archives of General Psychiatry, 32, 995– 1008.
84. Mahoney, M. J. (1979). Cognitive and non-cognitive views in behavior modification. In P. O. Sjoden & S. Bates (Eds.), Trends in behavior therapy (pp. 39–54). New York: Plenum Press.
85. Marks, I. M., & Gelder, M. G. (1966). Common ground between behavior therapy and psychodynamic methods. British Journal of Medical Psychology, 39, 11–23.
86. Marmor, J. (1962). Psychoanalytic therapy as an educational process. Science and Psychoanalysis, 7, 286–299.
87. Marmor, J. (1964). Psychoanalytic therapy and theories of learning. Science and Psychoanalysis, 7, 265–279.
88. Marmor, J. (1976). Common operational factors in diverse approaches to behavior change. In A. Burton (Ed.), What makes behavior change possible? (pp. 3–12). New York: Brunner/ Mazel.
89. Marmor, J. (1982). Change in psychoanalytic treatment. In S. Slipp (Ed.), Curative factors in dynamic psychotherapy (pp. 60–70). New York: McGraw-Hill.
90. Marmor, J., & Woods, S. M. (Eds.). (1980). The interface between psychodynamic and behavioral therapies. New York: Plenum Press.
91. Masserman, J. (1980). Principles and practice of biodynamic psychiatry. New York: Thieme-Stratton.
92. McCullough, J. P. (2000). Treatment for chronic depression: Cognitive-behavioral analysis system of psychotherapy. New York: Guilford Press.
93. Messer, S. B. (1992). A critical examination of belief structures in integrative and eclectic psychotherapy. In M. Goldfried & J. Norcross (Eds.), Handbook of psychotherapy integration (pp. 131–165). New York: Basic Books.
94. Messer, S. B. (2001). Introduction to the special issue on assimilative integration. Journal of Psychotherapy Integration, 11, 1–4.
95. Mitchell, S. (1988). Relational concepts in psychoanalysis. Cambridge, MA: Harvard University Press.
96. Murray, E. J., & Jacobson, L. I. (1971). Cognition and learning in traditional and behavioral psychotherapy. In M. Lambert & A. Bergin (Eds.), Handbook of psychotherapy and behavior change (pp. 661–688). New York: Wiley.
97. Newman, M. G., Castonguay, L. G., & Borkovec (1999, April). New dimensions in the treatment of generalized anxiety disorder: Interpersonal focus and emotional deepening. Paper presented at the 15th Annual Meeting of the Society for the Exploration of Psychotherapy Integration, Miami, FL.
98. Newman, M. G., Castonguay, L. G., Borkovec, T. D., & Molnar, C. (in press). Integrative therapy for generalized anxiety disorder. In R. G. Heimberg, C. L. Turk, & D. S. Mennin (Eds.), Generalized anxiety disorder: Advances in research and practice. New York: Guilford Press.
99. Norcross, J. C. (Ed.). (1986). Handbook of eclectic psychotherapy. New York: Brunner/Mazel.
100. Norcross, J. C., & Beutler, L. E. (2000). A prescriptive eclectic approach to psychotherapy training. Journal of Psychotherapy Integration, 10, 247–261.
101. Norcross, J. C., & Goldfried, M. R. (Eds.). (1992). Handbook of psychotherapy integration. New York: Basic Books.
102. Norcross, J. D., & Newman, C. F. (1992). Psychotherapy integration: Setting the context. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 3–45). New York: Basic Books.
103. Orlinsky, D. E., & Howard, K. I. (1987). A generic model of psychotherapy. Journal of Integrative and Eclectic Psychotherapy, 6, 6–27.
104. Piper, W. E., Joyce, A. S., Rosie, J. S., Ogrodniczuk, J. S., McCallum, M., O’Kelly, J. G., & Steinberg, P. I. (1999). Prediction of dropping out in time-limited interpretive individual psychotherapy. Psychotherapy, 36, 114–122.
105. Prochaska, J. O., & DiClemente, C. C. (1992). The transtheoretical approach. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 300–334). New York: Basic Books.
106. Rhoads, J. M., & Feather, B. W. (1972). Transference and resistance observed in behavior therapy. British Journal of Medical Psychology, 45, 99–103.
107. Ricks, D. F., Wandersman, A., & Poppen, P. J. (1976). Humanism and behaviorism: Toward new syntheses. In A. Wandersman, P. J. Poppen, & D. F. Ricks (Eds.), Humanism and behaviorism: Dialogue and growth (pp. 383–402). Elmsford, NY: Pergamon Press.
108. Robertson, M. H. (1986). Training eclectic psychotherapists. In J. Norcross (Ed.), Handbook of eclectic psychotherapy (pp. 416– 435). New York: Brunner/Mazel.
109. Rogers, C. R. (1981). Book jacket comment. In P. Pentony (Ed.), Models of influence in psychotherapy. NewYork: Macmillan.
110. Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psychotherapy. American Journal of Orthopsychiatry, 6, 412–415.
111. Safran, J. D. (1990a). Towards a refinement of cognitive therapy in light of interpersonal theory, I. Theory. Clinical Psychology Review, 10, 87–105.
112. Safran, J. D. (1990b). Towards a refinement of cognitive therapy in light of interpersonal theory, II. Practice. Clinical Psychology Review, 10, 107–121.
113. Safran, J. D. (1998). Widening the scope of cognitive therapy. Northvale, NJ: Aronson.
114. Safran, J. D., & Segal, Z. V. (1990). Interpersonal process in cognitive therapy. New York: Basic Books.
115. Samilov, A., & Goldfried, M. R. (2000). Role of emotion in cognitive-behavior therapy. Clinical psychology: Science and Practice, 7, 373–385.
116. Schut, A. J., & Castonguay, L. G. (2001). Reviving Freud’s vision of a psychoanalytic science: Implications for clinical training and education. Psychotherapy, 38, 40–49.
117. Shearin, E. N., & Linehan, M. M. (1992). Dialectical behavior therapy for borderline personality disorder: Theoretical and empirical foundations. Acta psychiatrica scandinavica, 92, 155– 160.
118. Shectman, F. (1977). Conventional and contemporary approaches to psychotherapy: Freud meets Skinner, Janov and others. American Psychologist, 32, 197–204.
119. Sloane, R. B. (1969). The converging paths of behavior therapy and psychotherapy. American Journal of Psychiatry, 125, 877–885.
120. Stiles, W. B., Meshot, C. M., Anderson, T. M., & Sloan, W. W. (1992). Assimilation of problematic experiences: The case of John Jones. Psychotherapy-Research, 2, 81–101.
121. Stiles, W. B., Shankland, M. C., Wright, J., & Field, S. D. (1997). Aptitude-treatment interactions based on clients’ assimilation of their presenting problems. Journal of Consulting and Clinical Psychology, 65, 889–893.
122. Stricker, G. (1994). Reflections on psychotherapy integration. Clinical Psychology: Science and Practice, 1, 3–12.
123. Stricker, G., & Gold, J. R. (Eds.). (1993). Comprehensive handbook of psychotherapy integration. New York: Plenum Press.
124. Strupp, H. H. (1973). On the basic ingredients of psychotherapy. Journal of Consulting and Clinical Psychology, 41, 1–8.
125. Strupp, H. H. (1976). Some critical comments on the future of psychoanalytic therapy. Bulletin of the Menninger Clinic, 40, 238–254.
126. Thoresen, C. E., & Coates, T. J. (1978). What does it mean to be a behavior therapist? Counseling Psychologist, 7, 3–21.
127. Tobin, S.A. (1990). Self psychology as a bridge between existentialhumanistic psychology and psychoanalysis. Journal of Humanistic Psychology, 30, 14–63.
128. Tobin, S. A. (1991). A comparison of psychoanalytic self psychology and Carl Rogers’s person-centered therapy. Journal of Humanistic Psychology, 31, 9–33.
129. Torrey, E. F. (1972). What western psychotherapists can learn from witch-doctors? American Journal of Orthopsychiatry, 42, 69–76.
130. Tseng, W. S., & McDermott, J. F. (1979). Psychotherapy: Historical roots, universal elements, and cultural variations. American Journal of Psychiatry, 132, 378–384.
131. Wachtel, P. L. (1977). Psychoanalysis and behavior therapy: Toward an integration. New York: Basic Books.
132. Wallerstein, R. S., & DeWitt, K. N. (1997). Intervention modes in psychoanalysis and in psychoanalytic psychotherapies: A revised classification. Journal of Psychotherapy Integration, 7, 129–150.
133. Weinberger, J. (1993). Common factors in psychotherapy. In G. Stricker & J. Gold (Eds.), Comprehensive handbook of psychotherapy integration (pp. 9–26). New York: Plenum Press.
134. Winnicott, D. W. (1989). Psychoanalytic explorations. Cambridge, MA: Harvard University Press. (Original work published 1969)
135. Wolfe, B. E. (1992). Integrative psychotherapy of the anxiety disorders. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp. 373–401). New York: Basic Books.
136. Wolfe, B. E. (2000). Toward an integrative theoretical basis for training psychotherapists. Journal of Psychotherapy Integration, 10, 223–246.
137. Yalom, I. D. (1980). Existential psychotherapy. New York: Basic Books.